Provider Demographics
NPI:1376296202
Name:FOREVER PLACE BEHAVIORAL LLC
Entity Type:Organization
Organization Name:FOREVER PLACE BEHAVIORAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LACHONIQUIE
Authorized Official - Middle Name:KIERRA
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:567-225-4008
Mailing Address - Street 1:2400 N BULLARD AVE APT 2009
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-3305
Mailing Address - Country:US
Mailing Address - Phone:567-225-4008
Mailing Address - Fax:
Practice Address - Street 1:2356 N SAND HILLS CT
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6664
Practice Address - Country:US
Practice Address - Phone:567-225-4008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOREVER PLACE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1356948954Medicaid